If every person who ever experienced a traumatic event always suffered
from PTSD, the disorder would become almost as common as colds or flu. Clearly not everyone is affected to that same degree.
Research studies that have examined the causes of PTSD are scarce. It is still difficult to identify those most likely to be affected, and those at greatest risk. Very little of the research is conclusive and any figures quoting a person's `PTSD risk' are likely to be contested by various bodies having a vested
interest in either underestimating or overestimating the figures. Defence departments will play down the figures. When asked about PTSD cases in 1994, the Ministry of Defence in London claimed that only 68 British combat troops received any form of psychiatric treatment as a direct result of the Gulf War. The independent group, TACT (the Trauma After Care Trust), claimed that the figure to be at least 13,000. The reality has proved to be far worse than either of these early predictions.
First it is necessary to look at the groups of people likely to suffer with PTSD.
Primary victims are those who experienced the life-threatening situation first hand. In many instances they are easily identified. The survivors of a major disaster stand a 30-60 per cent risk of developing Post Traumatic Stress Disorder. The risk will vary according to the degree of perceived risk, the duration, and the scale of the event. In many of these cases, people now anticipate a reaction to the trauma. Allowances are made for the victims and it is generally acknowledged that they have experienced an incredible shock. Those involved in a well-publicised tragedy will be overwhelmed by the warmth and compassion of the sympathy expressed towards them.
The novelty wears off after a while. As time passes, those around the victim may be heard to comment that `It's time she snapped out of it', or `He should pull himself together and get on with life' .Comments like these show a lack of understanding of PTSD. Not all primary victims are so obvious. Many life-threatening events go unnoticed by the rest of society. A rape victim may hide her trauma for months, or even years. A victim of incest may always feel unable to disclose the abuse. Victims of bullying are frightened or threatened into keeping quiet. An abused child may simply be labelled hyperactive, or uncontrollable. Many of the children taken into care
for their own protection and welfare are actually suffering some of the symptoms of PTSD (Smith 1986). These personal traumatic experiences are the most difficult to talk about, and the most difficult to treat.
The family and friends of victims often become victims of PTSD themselves. There are two main reasons for this. First, the family may witness scenes from the trauma, either first hand, or by courtesy of the media. For example, many people lost loved ones in the Lockerbie air crash in 1988, where 270 (259 passengers and 11 people on the ground) died. They cannot have avoided seeing the scene on television during the following weeks. Seeing the devastation to the community of Lockerbie and the contorted frame of the nose of the aircraft in an open field could only add to the image of the suffering that might have been endured by a relative or friend. The criminal trial for this bombing was not concluded until January 31 2001.
Those close to the survivors of a disaster may also suffer in a similar way. In recent years Europe has witnessed two traumatic incidents which involved crowded football stadiums. In May 1985, 56 people died during crowd disturbances at the Heysel Stadium in Belgium. Four years later, overcrowding at the Hillsborough Stadium in England resulted in the deaths of 97 people. The last of these victims lived until 1993 when mechanical life support was suspended. Both incidents involved supporters of Liverpool Football Club, and both events were screened live on television. Relatives and friends watched the live television pictures in horror as people were crushed before their eyes, knowing that somewhere in the crowd was a person they cared for deeply.
Once the survivors returned to the relative safety of their homes, they began to suffer vivid memories of the life-threatening event. Those around them also had mental images of the occasion, and witnessing the primary victim's suffering induced the disorder in secondary victims.
This sequence of events is not limited to disasters that have been broadcast on television. Many relatives witness the trauma first hand if it is a road accident, an assault, or a crime against property such as theft or burglary.
Tertiary victims are the onlookers or witnesses. They have no link with any person directly involved in the life-threatening event, but they saw what happened. If the event is serious, these
victims will probably be called to court or a hearing of some kind to give evidence. Giving evidence is a trauma in itself. The worry of such an ordeal hanging over them for months, sometimes years, means that witnesses are not permitted the luxury of forgetting. Society demands that they keep the memory fresh.
Witnesses, like primary victims, just happen to be there at the time. However, if you are so close to an event that you see it, then before long you are nagged by the thought that `it could have happened to me' .If it is a road accident then that is not an irrational thought, it is a reality. In consequence, the witnesses may also feel that they have been prey to a life-threatening event. They could have been seriously injured or killed.
THE RESCUERS AND THE CARERS
To a degree, the only victims of PTSD who can prepare themselves to deal with life-threatening events are rescuers and carers. Their job demands that they become involved with primary victims. This involvement is on a deep and personal level for fire, police and ambulance personnel, doctors, nurses, paramedics and counsellors.
Many of these professional people wear a uniform. This may assist at the time. Hiding behind a uniform can be an asset in certain circumstances, but when the uniform is removed, all that remains is another frail human being. True, this is a well-trained, experienced and professional person, but he or she may only face a major disaster once or twice in a working lifetime.
In less traumatic situations, it may be one aspect of the incident which
affects professionals in a way that could not have been predicted. In the Lockerbie incident, emergency staff suffered from shock brought about by the meaninglessness of the tragedy. Cases of PTSD were being diagnosed up to two years after the disaster.
The victims of PTSD are many. Those who are not primary victims of the disorder are frequently referred to as hidden victims. For every primary victim of PTSD there could be as many as three hidden victims.
SO WHY ME?
PTSD is selective. Not everyone is affected. Unfortunately, it is not possible to predict who will be affected by this disorder. (A few may disagree with this statement!)
There are some indications, however, that particular groups of people may be more susceptible to the disorder than others. People who possess an introverted personality may be at slightly greater risk. A family history of anxiety or depression may be a contributing factor. These ideas are based upon very limited research studies purely because PTSD is such an impossible disorder to monitor.
It appears likely that a person with pre-existing difficulties which create a stressful lifestyle, may have already stretched his or her psychological and emotional defences to near breaking point. The life-threatening trauma will be the final straw.
Carers and rescue workers can have risks reduced by careful training and preparation to expect trauma. Once a traumatic event has been experienced, the personnel involved must be fully, and professionally, counselled in a procedure known as Critical Incident Debriefing (Parkinson 1993).
Nevertheless, a trauma may be so devastating that it affects even the strongest character. It is totally unreasonable for anyone to suggest that PTSD is self-induced or that if only you could pull yourself together things would be just fine.